Healthcare Provider Details

I. General information

NPI: 1225532849
Provider Name (Legal Business Name): CRADLESTONE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 SE BAYSHORE DR # 201
OAK HARBOR WA
98277-5701
US

IV. Provider business mailing address

PO BOX 891
OAK HARBOR WA
98277-0891
US

V. Phone/Fax

Practice location:
  • Phone: 360-682-5519
  • Fax:
Mailing address:
  • Phone: 360-682-5519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number604194142
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number604194142
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number604194142
License Number StateWA

VIII. Authorized Official

Name: MR. CHRISTOPHER JOHN WIEGENSTEIN
Title or Position: CEO/COUNSELOR
Credential: AS, BA, MS
Phone: 360-682-5519